Volume 138, Issue 1, Pages 360-371.e7 (January 2010) ERK1/2-Dependent Vascular Endothelial Growth Factor Signaling Sustains Cyst Growth in Polycystin-2 Defective Mice  Carlo Spirli, Stefano Okolicsanyi, Romina Fiorotto, Luca Fabris, Massimiliano Cadamuro, Silvia Lecchi, Xin Tian, Stefan Somlo, Mario Strazzabosco  Gastroenterology  Volume 138, Issue 1, Pages 360-371.e7 (January 2010) DOI: 10.1053/j.gastro.2009.09.005 Copyright © 2010 AGA Institute Terms and Conditions

Figure 1 Expression of VEGF, VEGFR-2, and HIF-1α in ADPKD mice. (A) WT, (B) Pkd1KO, and (C) Pkd2KO mice were stained with H&E or with specific antibodies against VEGF, VEGFR-2, and HIF-1α. In cystic epithelium (B and C), immunoreactivity for VEGF, VEGFR-2, and HIF-1α (arrows) is clearly positive. H&E stain: original magnification 10×. VEGF, VEGFR-2, and HIF-1α: original magnification 40×. See Supplementary Materials and Methods for methodological details. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Figure 2 Inhibition of VEGFR-2 (SU5416) reduces cystic area in Pkd2KO mice. (A) Paraffin-embedded liver sections were labeled with a pancytokeratin antibody to discriminate between vessels and cystic structures. Micrographs are representative of vehicle- (left) and SU5416-treated mice (right). (B) Morphometric analysis was performed as described in Materials and Methods and Supplementary Materials and Methods. A significant reduction in cystic area was observed in Pkd2KO animals. (C) The decrease in cyst development is reflected also in the significant reduction in liver/body weight ratio. *P < .05 vs Pkd1KO vehicle; &P < .01 vs Pkd2KO vehicle; #P < .05 vs WT vehicle; §P < .05 vs Pkd2KO vehicle. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Figure 3 PCNA and pERK are reduced after SU5416 treatment in Pkd2KO mice. Cystic cholangiocytes showed strong proliferative activity (A, PCNA staining) and (D) pERK expression, particularly in Pkd2KO mice. As shown in the bar graphs, a significant reduction in (B) PCNA and (E) pERK expression, assessed by (B and E) morphometric analysis and by (C and F) Western blot, was observed in Pkd2KO-treated animals, while no significant changes were observed in Pkd1KO mice. #P < .05 vs Pkd1KO vehicle; *P < .05 vs Pkd2KO vehicle. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Figure 4 Pkd2KO cystic cholangiocytes significantly secrete more VEGF and express more VEGFR-2 in respect to Pkd1KO. (A) Cystic cholangiocytes isolated from Pkd2KO mice secreted a significantly higher amount of VEGF in respect to cells isolated from Pkd1KO and WT mice. (C) VEGFR-2 expression and (D) phosphorylation after treatment with VEGF (25 ng/mL, 10 minutes) are significantly higher in Pkd2KO compared with Pkd1KO mice (n = 4). (B) Representative example of Western blot. *P < .05 vs WT and Pkd1KO mice. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Figure 5 Overactivation of ERK and VEGF secretion in Pkd2 cholangiocytes is PKA dependent. Normal and cystic cholangiocytes were treated with the PKA inhibitor PKI (1 μmol/L), and pERK expression was assessed by Western blot while VEGF secretion was assessed by enzyme-linked immunosorbent assay. (A) Representative blot showing the reduction of pERK/ERK ratio in cells treated with PKI (1 μmol/L). (B) Data from 3 different experiments are shown in the bar graph. (C) In a similar manner, PKI inhibited VEGF secretion. *P < .05 vs WT and Pkd1KO controls; #P < .05 vs Pkd2KO controls. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Figure 6 VEGF-induced ERK phosphorylation is significantly higher in Pkd2KO cystic cholangiocytes. Cells were treated with VEGF 25 ng/mL for 5-10-15-30 minutes or 10 minutes in presence of SU5416, a VEGFR-2 inhibitor, and then lysated for Western blot analysis. A clear time course in ERK phosphorylation with a significantly more pronounced effect in Pkd2 cystic cholangiocytes is shown. SU5416 (5 μmol/L) completely inhibited ERK phosphorylation in cells treated with VEGF for 10 minutes (n = 3). #P < .05 vs WT and Pkd1KO mice; *P < .05 vs WT and Pkd1KO 10 minutes; °P < .05 vs VEGF 10 minutes. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Figure 7 VEGF-induced cell proliferation is MEK/ERK mediated. VEGF significantly enhances cell proliferation in both WT cholangiocytes and Pkd2KO cystic cholangiocytes, but this effect is significantly greater in Pkd2KO cells. VEGF-induced cell proliferation was inhibited by (A) ERK1/2 siRNA or by (B) treatment with an MEK inhibitor (U1026, 10 μmol/L). §P < .01 vs controls; *P < .01 vs Scramble+VEGF; •P < .01 vs controls; #P < .01 vs VEGF-treated cells; ^P < .05 vs controls. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Figure 8 ERK-mediated VEGF secretion and cell proliferation in Pkd2KO cystic cholangiocytes: working model. Defects in PC2 function may influence VEGF signaling via PKA-mediated stimulation of ERK1/2. As a consequence, VEGF production is enhanced by HIF-1α induction and, through an autocrine effect on cystic cholangiocytes, stimulates cell proliferation. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Supplementary Figure 1 Cre reporter gene analysis in bile ducts. (A) pCxCreER:RA/EG mice induced with tamoxifen at 4 weeks showing enhanced green fluorescent protein epifluorescence from the RA/EG reporter locus9 as an indicator of Cre activity in bile ducts (arrow). (B) Liver cysts in tamoxifen-treated Pkd2flox/−:pCxCreER;Rosa26R mice show β-galactosidase immunoreactivity (green) in cyst linings derived from bile ducts, demonstrating the concordance of loss of PC2 with the occurrence of cysts. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Supplementary Figure 2 CD34 stains pericystic vascular structures in Pkd1KO and Pkd2KO mice. Paraffin-embedded liver sections (5 μmol/L) were stained with an anti-CD34 and with an anti–cow cytokeratin wide spectrum (pancytokeratin). The figure shows lower (200×) and higher (400× and 1000×) magnification of liver cysts of (A and C) Pkd1KO and (B and D) Pkd2KO mice stained with anti-CD34 (red) to identify microvascular structures (arrows) and with pancytokeratin (green) to identify cystic epithelial cells (arrowheads). The number of C34-positive structures in the pericystic area is higher in Pkd2KO mice. See also the quantification in Figure 3. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Supplementary Figure 3 SU5416 treatment reduced the amount of CD34-positive areas in Pkd1KO and Pkd2KO mice. To calculate the vascular and biliary areas, 2 different thresholds were set out for CD34-positive (red fluorescence) and pancytokeratin-positive (green fluorescence) structures, respectively, and then expressed as percentage of pixels above the threshold per field. As shown in the bar graphs, treatment with SU5416 significantly reduced the CD34-positive area. (#P < .05 vs Pkd2KO vehicle; &P < .05 vs Pkd1KO vehicle). Pretreatment values were significantly higher in Pkd2KO than in Pkd1KO mice (1.17 ± 0.3 vs 0.57 ± 0.27; *P < .05 vs Pkd1KO vehicle). Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Supplementary Figure 4 Isolation and culture of cholangiocytes with defective polycystins. (A) In vivo cyst appearance, as shown by H&E, is resembled in cultured cells; (B) the cholangiocytes form an epithelial cell sheet spreading from the microdissected bile duct cultured in a collagen gel (original magnification 10×). (C) Cholangiocytes were cultured on semipermeable membrane inserts and stained with an anti-acetylated tubulin (cilium marker) antibody (green), a nuclear 4′,6-diamidino-2-phenylindole dye (blue), and an anti–cytokeratin-19 antibody (red). (D) Cultured cells are well differentiated and maintain a correct polarization, as shown in the electron micrograph. These cultures were negative for the endothelial cells marker CD31 (not shown), excluding contamination with endothelial cells. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Supplementary Figure 5 Increased HIF-1α expression and VEGF secretion in Pkd2KO cystic cholangiocytes is MEK dependent. (A) HIF-1α accumulation and (B) VEGF secretion induced by DMOG (3 mmol/L) are significantly higher in Pkd2KO cystic cholangiocytes with respect to WT cholangiocytes. This effect was completely blunted in cells treated with the MEK inhibitor U10269 (10 μmol/L) (**P < .001 vs Pkd2KO controls; #P < .001 vs DMOG-treated cells) (n = 3). Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions

Supplementary Figure 6 VEGF-induced ERK phosphorylation is significantly higher in Pkd2KO cystic cholangiocytes. Cells were treated with VEGF 25 ng/mL for 10 minutes and then lysate for Western blot analysis. ERK phosphorylation had a significantly more pronounced effect in Pkd2 cystic cholangiocytes, as shown in the representative Western blot in which 3 bands from 3 different experiments are shown. Optical density quantification is shown in the bar graph. *P < .05 vs WT and Pkd1KO mice. Gastroenterology 2010 138, 360-371.e7DOI: (10.1053/j.gastro.2009.09.005) Copyright © 2010 AGA Institute Terms and Conditions